Please be honest when filling out this form. If you do not
fully disclose information asked, any services we may provide based on the
information you give us could result in an unfavorable outcome, which we will
not be liable for. The information you provide is in confidence and will not be
shared with outside parties.

How long have you been dealing with acne? *

How is acne affecting your lifestyle? (Did you miss out on any activity or social events; are you embarrassed by your own skin; are you frustrated with having breakouts all the time etc. ?) *

What kind of treatments, medications and products have you tried before? And what were the results from these services? *

Client Questionnaire

Prescribed medications, Over the Counter products and Procedures for Acne (Past and Present)

Are you currently using any medications? (Check all that Apply)

Accutane/Isotretinoin

Aldactone/Spironolactone

Oral Tetracycline

Oral Doxycycline

Oral Minocycline

Topical Erythromycin

Topical Clindamycin

Aczone (Dapsone)

Benzoyl Peroxide (BPO)

Benzamycin (BPO + Erythromycin)

BenzaClin/Duac/Acanya/Onexton/ (BPO + Clindamycin)

Birth Control Pills for acne (Ortho-Tricyclen/Yaz)

Chemical Peel

Blue Light LED Therapy (Targets Bacteria)

Tazorac/ Avage Gel

Tazorac/ Avage Cream

Atralin/Avita/Retin-A/Tretinoin GEL

Avita/Retin-A/ Tretinoin CREAM

Ziana (Tretinoin + Clindamycin)

Differin

Epiduo (Differin + BPO)

Sulfur

Finacea/Azelex/Metrogel/Mirvaso

Cortisone Injections (targets inflammation)

Cleocin-T

E-mycin-T

Androstendione

Thyroid Medication

Minosine

Copaxone

Testosteron

Progesterone

Disufuram

Dilantin

Lithium

Quinine

Isoniazid

Immuran

Danzol

Cocain/ Speed

Marijuana

Steroids

OTHER

**IF OTHER PLEASE LIST NAMES

Please describe any dates used for the above medications and let us know if it has helped or made your condition worse:

Discribe the products that you are currently using

Write brand and name

Cleanser brand and name:

Toner brand and name:

Serum brand and name:

Moisturizer brand and name:

Eye Cream brand and name:

Acne Product brand and name:

Sunscreen Brand and name:

Mask brand and name:

Liquid Foundation brand and name:

Powder foundation brand and name:

Concealer to cover blemishes brand and name:

Concealer (under eye) brand and name:

Blush brand and name:

Bronzer brand and name:

Eye Makeup Remover brand and name:

Shampoo brand and name:

Conditioner brand and name:

Leave-on Hair Product brand and name:

Toothpaste brand and name:

Lip Products brand and name:

OTHER brand and name:

Current Skin Care Routine (From List Above)

Morning:

Evening:

Weekly/Monthly:

ALLERGIES

Have you ever had any allergic reactions to anything you have ever put on your skin or do you have any food allergies? List what you were allergic to:

Check if you are allergic to:

SULFUR

ASPIRIN

LATEX

BENZOYL PEROXIDE

Important questions about your acne

At what age did you started to break out?

Have you been diagnosed with rosacea?

What are your top areas of concern?

Forehead

Hairline

Cheeks

Chin

Nose

Jawline

Front of neck

Back

Shoulders

Chest

Back of Neck

Important Questions about your Lifestyle:

Do you smoke cigarettes?*

No

Yes

Do you use fabric Softener or dryer sheets?*

No

Yes

Do you pick at your skin?*

No

Yes

Do you use any tools to pick your skin? (Describe)

Are you currently pregnant or trying to become pregnant

Are you on birth control? Which brand?

Do you play any musical instrument?*

No

Yes

Do you play any sport? List:

Important Questions about Your Eating Habits

Do you regularly eat or drink? (Check all that apply)

Cow's milk

Yogurt

Cheese

Sweets, sugary foods

Salty food

Chinese Food

Processed Foods

Peanut butter

Kelp

Seaweed

Sushi rolls

Fast Food

Sports drinks

Soy

Are you a vegetarian?*

No

Yes

Are you willing to change your diet?*

No

Yes

Do you take any Medications or Nutritional Supplements: (Protein Powders, Shakes, Smoothies, Vitamins, Homeopathic medicine)

Medication or Supplement Brand:

How long have you been using it?

Reason for Use:

Guilty Pleasures:

Do you drink coffe?

Coffee cups/day:

Tea cups/day:

Caffeinated Sodas or diet Sodas?

Are you willing to give up on caffeinated products or reduce the amount your consuming?

Sugar Intake

Do you have frequent sugar cravings?*

No

Yes

How often a week do you eat sugary foods or beverages per week?

Stress/ Coping

Do you feel you have an excessive amount of stress in your life?*

No

Yes

Rate your daily stress (1 through 10):

Do you practice any relaxation techniques?*

No

Yes

If yes which one? How often?

Medical History

Do you ever experience digestive related issues? Please check all that apply.

Bloating

Constipation

Diarrhea

Acid Reflux

Stomach aches

(Check any condition you may have or had in the past:

Eczema/Psoriasis

HIV/AIDS

Hepatitis

Thyroid Problems

PCOS

Staph Infection

Cold Sores

Cancer

Hysterectomy / Ovaries removed

Lupus

Herpes simplex / Cold Sore

Additional Information

What kind of work do you do?

Are you currently under Dermatologists care? Please name and dates of care:

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.

Parent or Guardian's Name

First Name*

Last Name*

Phone*

Parent or Guardian's Date of Birth*

Parent or Guardian's Information

Please be honest when filling out this form. If you do not
fully disclose information asked, any services we may provide based on the
information you give us could result in an unfavorable outcome, which we will
not be liable for. The information you provide is in confidence and will not be
shared with outside parties.

How long have you been dealing with acne? *

How is acne affecting your lifestyle? (Did you miss out on any activity or social events; are you embarrassed by your own skin; are you frustrated with having breakouts all the time etc. ?) *

What kind of treatments, medications and products have you tried before? And what were the results from these services? *

Client Questionnaire

Prescribed medications, Over the Counter products and Procedures for Acne (Past and Present)

Are you currently using any medications? (Check all that Apply)

Accutane/Isotretinoin

Aldactone/Spironolactone

Oral Tetracycline

Oral Doxycycline

Oral Minocycline

Topical Erythromycin

Topical Clindamycin

Aczone (Dapsone)

Benzoyl Peroxide (BPO)

Benzamycin (BPO + Erythromycin)

BenzaClin/Duac/Acanya/Onexton/ (BPO + Clindamycin)

Birth Control Pills for acne (Ortho-Tricyclen/Yaz)

Chemical Peel

Blue Light LED Therapy (Targets Bacteria)

Tazorac/ Avage Gel

Tazorac/ Avage Cream

Atralin/Avita/Retin-A/Tretinoin GEL

Avita/Retin-A/ Tretinoin CREAM

Ziana (Tretinoin + Clindamycin)

Differin

Epiduo (Differin + BPO)

Sulfur

Finacea/Azelex/Metrogel/Mirvaso

Cortisone Injections (targets inflammation)

Cleocin-T

E-mycin-T

Androstendione

Thyroid Medication

Minosine

Copaxone

Testosteron

Progesterone

Disufuram

Dilantin

Lithium

Quinine

Isoniazid

Immuran

Danzol

Cocain/ Speed

Marijuana

Steroids

OTHER

**IF OTHER PLEASE LIST NAMES

Please describe any dates used for the above medications and let us know if it has helped or made your condition worse:

Discribe the products that you are currently using

Write brand and name

Cleanser brand and name:

Toner brand and name:

Serum brand and name:

Moisturizer brand and name:

Eye Cream brand and name:

Acne Product brand and name:

Sunscreen Brand and name:

Mask brand and name:

Liquid Foundation brand and name:

Powder foundation brand and name:

Concealer to cover blemishes brand and name:

Concealer (under eye) brand and name:

Blush brand and name:

Bronzer brand and name:

Eye Makeup Remover brand and name:

Shampoo brand and name:

Conditioner brand and name:

Leave-on Hair Product brand and name:

Toothpaste brand and name:

Lip Products brand and name:

OTHER brand and name:

Current Skin Care Routine (From List Above)

Morning:

Evening:

Weekly/Monthly:

ALLERGIES

Have you ever had any allergic reactions to anything you have ever put on your skin or do you have any food allergies? List what you were allergic to:

Check if you are allergic to:

SULFUR

ASPIRIN

LATEX

BENZOYL PEROXIDE

Important questions about your acne

At what age did you started to break out?

Have you been diagnosed with rosacea?

What are your top areas of concern?

Forehead

Hairline

Cheeks

Chin

Nose

Jawline

Front of neck

Back

Shoulders

Chest

Back of Neck

Important Questions about your Lifestyle:

Do you smoke cigarettes?*

No

Yes

Do you use fabric Softener or dryer sheets?*

No

Yes

Do you pick at your skin?*

No

Yes

Do you use any tools to pick your skin? (Describe)

Are you currently pregnant or trying to become pregnant

Are you on birth control? Which brand?

Do you play any musical instrument?*

No

Yes

Do you play any sport? List:

Important Questions about Your Eating Habits

Do you regularly eat or drink? (Check all that apply)

Cow's milk

Yogurt

Cheese

Sweets, sugary foods

Salty food

Chinese Food

Processed Foods

Peanut butter

Kelp

Seaweed

Sushi rolls

Fast Food

Sports drinks

Soy

Are you a vegetarian?*

No

Yes

Are you willing to change your diet?*

No

Yes

Do you take any Medications or Nutritional Supplements: (Protein Powders, Shakes, Smoothies, Vitamins, Homeopathic medicine)

Medication or Supplement Brand:

How long have you been using it?

Reason for Use:

Guilty Pleasures:

Do you drink coffe?

Coffee cups/day:

Tea cups/day:

Caffeinated Sodas or diet Sodas?

Are you willing to give up on caffeinated products or reduce the amount your consuming?

Sugar Intake

Do you have frequent sugar cravings?*

No

Yes

How often a week do you eat sugary foods or beverages per week?

Stress/ Coping

Do you feel you have an excessive amount of stress in your life?*

No

Yes

Rate your daily stress (1 through 10):

Do you practice any relaxation techniques?*

No

Yes

If yes which one? How often?

Medical History

Do you ever experience digestive related issues? Please check all that apply.

Bloating

Constipation

Diarrhea

Acid Reflux

Stomach aches

(Check any condition you may have or had in the past:

Eczema/Psoriasis

HIV/AIDS

Hepatitis

Thyroid Problems

PCOS

Staph Infection

Cold Sores

Cancer

Hysterectomy / Ovaries removed

Lupus

Herpes simplex / Cold Sore

Additional Information

What kind of work do you do?

Are you currently under Dermatologists care? Please name and dates of care:

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.